Tadapox

In 1840 there was no Doppler radar or weather forecasting that could have produced an early warning for the citizens or sailors buy tadapox 80 mg low cost impotence age 45, which would have allowed them to take refuge before the tornado struck order 80 mg tadapox amex erectile dysfunction pre diabetes. Tere is always a possibility that during times of crisis modern medicine will not be available order tadapox 80 mg fast delivery erectile dysfunction louisville ky, so a contingency plan should be created to deal with such an event. Until science can predict such occurrences accurately, administrators will always need to have a plan to have their citizens take shelter on the possibility that a tor- nado can infict damage on a projected pathway. In the case of Natchez, there was no efective way to communicate with the residents on the river where the tornado chose as a pathway for destruction (Nelson, 2004). The takeaway for all administrators should be the importance of communi- cation for residents during a disaster response situation. Items of Note The single tornado that hit Natchez is still listed as the second deadliest in U. Goliad Tornado, Texas, 1902 Stage 1 of the Disaster You are the city administrator of a very small town. Services and resources are lim- ited and you have a restricted budget for municipal facilities. The city administrator should attempt to get communication out to the residents telling them to take shelter immedi- ately. In addition, all frst responders should be put on alert as well as inform- ing the city council that a potential disaster could be eminent. The city administrator should take an inventory of all of the resources that the city currently has at its disposal for an emergency. The city administrator should also contact other cities to see if resources can be obtained, as well as seek permission to transport any casualties to their medi- cal facilities since your city has very little in the way of proper hospital care. The city administrator should mobilize frst responders and medical personnel as quickly as possible for the damage that will potentially occur. In addition, the city administrator should fnd as many areas that can shelter residents as possible. Stage 2 of the Disaster As the tornado moves through your city, a number of houses and businesses are fattened. You observe the African-American Methodist Church being destroyed Case Studies: Disasters from Natural Forces—Tornadoes ◾ 75 by the tornado (Victoria Internet Providers, 2007). The tornado has now passed through your city, leaving death and destruction in its path. Since the city has no hospital, the city admin- istrator will need to designate a facility to serve this purpose. The city administrator needs to direct search and rescue personnel to fnd anyone that may be trapped under the rubble or injured. The next step is to tri- age the injured persons at the designated hospital, have medical personnel take care of the worst injured persons frst and then, if possible, transport those that are in stable condition to surrounding communities’ medical facilities. Shelter, medical supplies, food, and water will be the top items to gather for a city that has been hit by a natural disaster on this scale. Additionally, at some point getting communications reestablished with the surrounding communities as well as efective transpor- tation will be essential. Since you do not have proper facilities, you turn the Goliad County Courthouse into a temporary hospital and morgue (Victoria Internet Providers, 2007). Any infrastructure that has been damaged will need to be repaired, and to do so Goliad will need communities to donate supplies and workers to assist with those repairs. Additionally, you will need to fnd medical assistance and frst responders from surrounding communities. Key Issues Raised from the Case Study Tis tornado resulted in 114 people killed (50 were killed in the Methodist Church alone), 230 people injured, and an estimated $50,000 worth of damage (in 1902 dollars) (Victoria Internet Providers, 2007). Terefore, it is more important for those types of organizations to have agreements and arrangements with surrounding organizations to provide support in times of crisis. Goliad did not appear to have a plan (or a hardened shelter) to provide safety to its residents against tornadoes. Construction around the early 1900s largely con- sisted of wooden structures that would not have withstood tornadoes. In Texas, tor- nadoes are common and cities in tornado zones should have an emergency action plan to contend with sheltering residents, obtaining resources (i. The ofcials in Goliad did make adjustments to the lack of facilities and used the courthouse, for example, as a stopgap solution to a defciency that the city had with facilities in a time of crisis. One of the frst actions that the director needs to take is to make contact with the governors of the three states where storm activity is taking place and determine if there are any plans to contend with natural disasters. In addition, the director should assess where federal resources are located for emergency management purposes and put certain personnel on notice that they may be deployed to a disaster area. The director should also make sure that he or she has sufcient communication pathways established to receive incoming reports on weather and needs that may arise from the three diferent states. The director should coordinate with all federal agencies that can provide any type of assistance or resources in case of an emergency (e. At the state level, it is important for the director to keep in constant contact with the governor’s ofce in each state about the situation as well as what resources each state can assemble in times of crisis. Stage 2 of the Disaster You are now receiving reports that there are several tornadoes that are occurring across three states. A town named Murphysboro has been completely obliterated by a tornado (Ishman, 2001). As director you need to see how many medical and recovery teams you can assemble from federal agencies. In addition, the director can put a call out to other state and local agencies that may be able to send additional resources to Murphysboro. Food, water, shelters, medical supplies, and excavation equipment will need to be sent to Murphysboro as soon as possible. The director needs to stay in constant contact with on-site supervisors to notify them of the situation as it develops so that more resources can be deployed if necessary. Additionally, the director should maintain contact with other federal agencies as well as state ofcials to ensure that the eforts are coordinated and efective. Stage 3 of the Disaster You now have received reports that approximately 250 people have died in Murphysboro, another 500 are wounded, and fres have broken out across the city causing property damage (Ishman, 2001). Search and rescue teams will become even more critical to survivors who may be trapped under- neath the rubble of destroyed buildings. Priority should be given to deploy search and rescue teams and obtain medical supplies. Any type of frefght- ing apparatus that can be assembled and deployed to Murphysboro should also be given a high priority so that more buildings are not destroyed and those surviving buildings can provide shelter for anyone that may be dis- placed. Besides food and water, there also needs to be some thought given to requesting security forces to the area to prevent criminal activity from occurring. Once the search and rescue phase of the operation is completed, the recovery of bodies will be the next step, as well as constructing any type of temporary housing that may be required. If the wounded can be moved to other hospitals in the area, they should be transported to alleviate the burden on local medical facilities.

The length of the ventriculotomy is exaggerated in this fgure to allow visualization of intracardiac structures discount tadapox 80 mg fast delivery erectile dysfunction high cholesterol. The top end of the incision should be several millimeters from the truncal valve and the right coronary artery purchase discount tadapox impotence caused by medications. There is usually considerable disparity in size between the ascending aorta and original truncus necessitating aggressive tailoring of the anasto- mosis to match the two vessels cheap tadapox amex erectile dysfunction medication new. A separate hood of pericardium is not required in contrast to the situation when a pulmonary or aortic homograft is used. Two atrial and nal diameter of the homograft is generally in the region of one ventricular pacing wires are placed. The homograft is older infant, that is, greater than 3–6 months in whom there is concern that pulmonary resistance is elevated. Exposure of this anastomosis is Weaning from Bypass facilitated by the fact that the truncus has not yet been recon- When the rectal temperature has reached 35°C, the child is stituted (Fig. Following removal of Ascending Aortic Anastomosis the cannulas, protamine is given. Hemostasis is assisted with The proximal truncus is anastomosed to the distal ascend- thrombin-soaked gelfoam. Chest tubes are placed and the chest is closed of the disparity in size, it is necessary to aggressively tailor in the routine fashion. It should rarely be necessary in the full- down the proximal truncus by taking wide bites on the trun- term neonate to leave the sternum open. If the disparity is greater than 2:1 which is not uncommon, it is preferable Management of the Regurgitant Truncal Valve to take a tuck on the rightward and posterior aspect in what The regurgitant truncal valve is almost always amenable to would usually be the noncoronary sinus. Replacement should rarely if ever in forming this dog ear, as well as in running the suture across be necessary in the neonatal period. One of the most useful the posterior wall to avoid any tension or distortion of the left techniques is to support a prolapsing leafet by suturing it to adjacent leafets (Fig. This is generally facilitated coronary ostium which should be carefully visualized. Prior by the fact that the prolapsing leafet is thickened and the to tying the suture anteriorly, the left heart should be allowed adjacent leafet edges are also relatively thickened and hold to fll with blood, and air should be vented through the suture sutures surprisingly well for a neonatal valve. Any remaining air is then vented through the original is often exacerbated by splaying of the tops of the commis- cardioplegia site. This can be improved by wedge excisions taken into the sinuses Proximal Homograft Anastomosis of Valsalva. It is even possible to completely excise leafets, The proximal anastomosis is simplifed if a femoral vein is including the adjacent sinus of Valsalva with reconstitution used. The autologous pericardium which was har- vested initially is used to roof the proximal anastomosis. Management of Associated Interrupted Toward the inferior end of the ventriculotomy there should Aortic Arch (Video 29. As described for the standard repair of truncus, depth to it rather than lying taut and fat. Before completion the child is cooled with a single arterial cannula in the dis- of this suture line, the left heart is once again de-aired and tal ascending aorta. The pulmonary arteries are occluded the aortic cross-clamp is released with gentle compression with tourniquets. Rewarming is begun and fow is grad- (see Chapter 32, Interrupted Aortic Arch) because fow to the ually increased. The open proximal homograft anastomosis descending aorta passes from the truncus through the ductus allows venting of blood from the right heart before cardiac arteriosus into the descending aorta. It is also possible to pass a sucker through perature is less than 15°C, the ascending aorta is clamped the homograft valve to vent the left heart if there is evidence and cardioplegia solution is infused into the truncal root, of left heart distention. Distention of the homograft is a use- while the ductus is controlled with forceps. Upon diffcult to distinguish ductal tissue, but if this is apparent it completion of the anastomosis, air is displaced by running should be excised. The remainder of the proce- the descending aorta to the site of excision of the pulmonary dure can be undertaken as for a standard repair. The arch anasto- is severely hypoplastic and will be inadequate to carry the mosis will be too proximal on the truncus and will interfere entire cardiac output. Instead, a longi- helpful to plasty the hypoplastic ascending aorta with a patch tudinal anastomosis should be made on the ascending aorta of autologous pericardium that extends from the proximal immediately proximal to the takeoff of the head vessels and perhaps extending a little on to the left common carotid artery truncal root to a point just beyond the anastomosis to the if this is a type B interruption (Fig. An alternative approach could aorta can be controlled with a C-clamp in order to reduce be to use a short segment of nonvalved femoral vein homo- tension on the anastomosis as this is fashioned. Tourniquets are no longer used on the pulmonary arteries to the proximal descending aorta. Because of the marked disparity between the proximal truncus and the distal ascending aorta, it is necessary to reduce the size of the proximal truncus by taking a tuck on the rightward and posterior aspect of the truncal root, thereby creating a dog ear. The ascending aorta is sutured to the left side of the truncal root which improves the lie of the homograft conduit. However, the patients who had more aggressive techniques were doing well at follow-up. The age who underwent primary repair of truncus arteriosus at median age at surgery was 2 weeks. Nine of the patients University of California, San Francisco between 1992 and had associated interrupted arch. A total of 23% of patients had moderate or severe trun- truncal valve regurgitation was diagnosed preoperatively, cal valve regurgitation and 12% had interrupted aortic arch. Five patients underwent months, there were two deaths resulting in a Kaplan–Meier truncal valve repair and one underwent homograft replace- estimate of survival at 1 year of 92%. The nifcantly associated with poorer survival over time were actuarial survival overall was 96% at 30 days, 1 and 3 years. The two deaths in the series occurred in patients replacement among early survivors was 57% at 3 years. None of the patients required with interrupted aortic arch and truncus at Royal Children’s reoperation because of truncal valve problems or aortic arch Hospital, Melbourne. Freedom from aortic reop- duit replacement was necessary in 17 patients after a mean eration was 76. Functional had an aortic homograft was 4 years and for those who had a status in all patients was good. Repeat surgical intervention truncal valvuloplasty methods has neutralized the traditional was rare and major complications related to root dilation did risk factor of truncal valve regurgitation. In this earlier timeframe, cal repair with a homograft conduit at Children’s Hospital truncal valve regurgitation, interrupted aortic arch, coronary Boston between 1990 and 1995. Although the early mortality artery anomalies, and age at repair greater than 100 days was satisfactory at 4.

Skull base reconstruc- vated further buy generic tadapox 80 mg online drugs for erectile dysfunction ppt, shrinking the tumor and causing the tumor tion was performed with an underlay and onlay fascia lata to collapse inward purchase genuine tadapox online erectile dysfunction dr. hornsby. Once it is felt that only a relatively thin shell of tumor remains generic tadapox 80mg overnight delivery erectile dysfunction at age 24, the surgical plane between the arachnoid and the brain is established and developed. A combination of mallea- Conclusion ble probes, suction Freer elevator, and neuropatties are used to mobilize the tumor from the brain. Vessels that are seen Endoscopic transnasal intracranial surgery is a new and ex- are mobilized and preserved or cauterized with the bipolar citing development in sinus surgery. In this patient the surgery went requires a high level of training and skill from both the sinus relatively uneventfully until a relatively large vein draining surgeon and the neurosurgeon. To perform such surgeries, the tumor into in the inferior sagittal sinus was avulsed from sinus surgeons and neurosurgeons need to form a skull base the sinus. Such a team should develop their endoscopic skills by 270 Endoscopic Sinus Surgery Fig. As References the level of expertise develops the team can tackle smaller selected intracranial tumors. Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience. Head Neck are vitally important to the success of the surgery and the 2006;28(10):867–873 team should always be mindful that surgery with the highest 2. Resection of anterior skull likelihood of success and least morbidity should be chosen. Am J Rhinol 2005;19(5):521–528 One of the most important aspects of this surgery is the two- 3. Having two surgeons operating at the scopic nasal and anterior craniotomy resection for malignant nasoethmoid same time has huge advantages for both the ability of the tumors involving the anterior skull base. Skull Base 2006;16(1):15–18 surgeons to remove the tumor by placing traction on it and 4. Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neo- for the management of complications especially if signif- plasms. Endo- base resection in the management of malignancies is still not scopic techniques in resection of anterior skull base/paranasal sinus clear but it is likely that endoscopic techniques will increas- malignancies. Endoscopic techniques for pathology ingly play a role in the management of these patients. J Am Coll Surg there is no substitute for a sound knowledge of anatomy and 2006;202(3):563 this chapter (and book) focuses on presenting the surgical 7. A reminder of cadaver dissections until the surgeon has extensive and de- the anatomy of the recurrent artery of heubner. Neurosurg with meningioma of the cranial base: secondary changes or tumor inva- Focus 2003;14(6):e4 sion. Reconstructive options for endo- from neurosurgical and ear, nose, and throat perspectives: approaches, scopic skull base surgery. Surgical outcomes of discussion 268–280 endoscopic management of adenocarcinoma of the sinonasal cavity. The pterional approach for Rhinology 2009;47(4):354–361 the microsurgical removal of olfactory groove meningiomas. A novel reconstructive tech- gery 1999;45(4):821–825, discussion 825–826 nique after endoscopic expanded endonasal approaches: vascular pedi- 16. Basilar invagination occurs when the tip to its location behind the nasopharynx and difcult to access of the odontoid moves more than 4. The traditional approach has from the back of the hard palate to the base of the occiput been the transoral approach. Addi- tionally the soft palate is split and portions of the hard palate are resected, depending on the access required. The disadvantages Chordoma of this approach are the need for a pre- and postoperative tra- cheostomy to secure the airway, contamination of the surgical Chordomas arise in the bone of the clivus and upper cervical feld with oral bacteria, the potential postoperative dysfunction spine from notochord remnants and are the most common of the soft palate in swallowing and phonation, and the need tumor of the mobile spine. These tumors rarely metastasize2 to feed the patient through a nasogastric tube postoperatively. Complete resection with postoperative surgery site is out of the swallowing mechanism, swelling is proton beam irradiation provides the best long-term survival. However, there are a small group of patients that fail multiple courses of radio- There are several pathologies that can be addressed with this therapy and may need salvage surgery if the tumor involves approach. In addition, multiple courses of radiotherapy may result in radio-osteonecrosis of this region, which in turn may require surgical debridement. The atlas has two thick lateral masses which4 Congenital Disorders articulate with the occipital condyles. The odontoid peg is po- There are several congenital odontoid malformations, basilar sitioned where the vertebral body of the atlas would normally invagination syndromes, and anomalies of the skull base that be and fxed to the clivus by the apical and alar ligaments. When this region is atlanto-occipital ligaments, arch of the atlas, and odontoid approached anteriorly the frst layer encountered is the na- peg (Figs. The peg is supported by sopharyngeal mucosa followed by the pharyngobasilar fascia, the apical and alar ligaments which form a secure attachment Fig. Posterior to the odon- A parasagittal view is also provided demonstrating the layers toid, the cruciate ligaments (vertical and horizontal elements) from anterior to posterior in this complex area. The cruciate ligaments are com- of the brainstem and lower cranial nerves are exposed. The monly afected by the rheumatoid pannus and weakened by medullary pyramids face the clivus with the hypoglossal the associated infammation. The supe- nerve has a cranial component whose rootlets hitch onto rior aspect of the cruciate ligament is cut away to give a view the vagus (Fig. Its spinal portion arises from a series of of the apical and alar ligaments of the odontoid peg (dens). This allows the soft tissue, bony landmarks, and vasculature to be accurately identifed. The anterior arch of the atlas has been thigh is prepared for harvesting of fat and fascia in case drilled away centrally to reveal the upper cervical spinal cord behind. C1 this may be needed in the reconstruction of the surgically and C2 spinal nerves can be seen clearly. The vertebral arteries pass lateral to the lateral Endoscopic Surgical Approach to the masses in the axis and enter the upper cervical region and Odontoid Peg then pass behind the occipital condyles to join anterior to the medulla to form the basilar artery (Figs. In patients with a chordoma extending down into the atlas, it may be necessary to resect the clivus from the foor of the pituitary fossa down to the base of the arch of the atlas (Fig. If the pathology is an invagination of the odontoid, opening of the sphenoid may not be required and the resection can be limited to the nasopharynx. To improve the postoperative healing a pedicled septal fap is elevated and placed in an opened maxillary sinus to move it out of the operative feld. A posterior septec- tomy is performed and the mucosa from the opposite poste- rior septal region is folded anteriorly to cover the donation site of the pedicled septal fap and secured anteriorly with sutures. Image guidance is used to map out the cervical carotid arteries to ensure that they are not in the surgical feld. In addition the clivus, anterior arch of the atlas, and body of the axis are identifed. The arch of the atlas is at the most caudal region that can be reached through the transnasal approach.

Pericarditis Grossly discount 80 mg tadapox visa impotence of proofreading poem, the pericardial surface may have a white order tadapox 80 mg line erectile dysfunction treatment new orleans, fibrinous proven 80mg tadapox impotence exercises, stringy to shaggy exudate; all cases show lymphocytic and mononuclear infiltration of the pericardium. Pericarditis heals with no significant adhesions, and constrictive carditis rarely occurs. Histologically, the myocardium may be edematous and show nonspecific inflammation. However, different from other forms of myocarditis, there is usually no evidence of cell damage. A variable degree of interstitial fibrinoid degeneration with inflammatory foci consisting of lymphocytes, macrophages, and other inflammatory cells has been reported as a common finding (141). Endocarditis Endocardial inflammatory changes are responsible for valvulitis and are therefore the most clinically significant. Small, 1 to 2 mm, friable, fibrinous, verrucous vegetations may occur on the atrial surface of the mitral valve or on the ventricular side of the aortic valve at sites of valve closure (144). With time, granulation tissue may occur, with thickening and eventually fibrosis of the valve. Similarly, chordal inflammation may be followed by granulation tissue, fibrosis, and eventually chordal fusion. Macroscopically, acute rheumatic mitral valvulitis results in elongation (or even rupture) of the chordae to the anterior mitral valve leaflet and annular dilation, resulting in altered leaflet coaptation, the potential for prolapse of the anterior leaflet, and mitral regurgitation (145,146). Vasculitis Generalized vasculitis, in particular involving the coronary arteries and the aorta, has been described (148). It resembles changes of hypersensitivity angiitis, but rarely results in tissue damage or clinical manifestations. Duckett Jones in 1944 (149), these criteria have undergone four revisions or modifications, the last in 1992 (150,151,152,153,154). Revisions and modifications have increased the specificity but decreased the sensitivity of the criteria to avoid overdiagnosis. The latest Updated Jones Criteria were published in 1992 and are intended to be used to establish the initial attack of P. The major criteria are polyarthritis, carditis, chorea, a characteristic rash called erythema marginatum, and subcutaneous nodules. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. Rheumatic fever diagnosis, management, and secondary prevention: a New Zealand guideline. Australian Guideline for Prevention, Diagnosis, and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. In Australia, the guidelines define different criteria for diagnosis in high-risk groups (see Table 59. On the other hand, steroids are of no therapeutic value in patients with chronic rheumatic valvular disease, and might delay more appropriate treatment. The Australia criteria for diagnosing a recurrence are 2 Major, or 1 Major + 1 Minor, or 3 Minor criteria + evidence of a preceding strep infection (171). In New Zealand, the criteria for diagnosing a recurrence are 2 Major, or 1 Major + 2 Minor, or several Minor + evidence of a preceding strep infection (169) (see Table 59. Of the major Jones criteria, migratory polyarthritis is most common, affecting 40% to 70% of cases (Table 59. Importantly, the presentation and evolution of the joint manifestations may be affected by administration of anti-inflammatory medications (aspirin or other nonsteroidal anti-inflammatory agents). It is noteworthy that in some parts of the world, monoarticular arthritis is a common mode of presentation (155,173). In some cases, the joints may be involved sequentially and simultaneously rather than in a migratory pattern, with a new joint becoming involved while a different joint is at a different phase of inflammation and resolution. Although carditis and arthritis commonly occur together, the severity of the joint and heart involvement tend to be inversely related (129). The reasons for this inverse relationship are unclear; some have speculated that joint involvement leads to earlier medical attention and initiation of anti- inflammatory treatment, thus preventing more severe cardiac involvement. Because of the different latency periods between the preceding streptococcal pharyngitis and the onset of symptoms, polyarthritis and chorea uncommonly occur simultaneously (174). In fact, lack of clinical response and improvement within 2 to 3 days should prompt consideration of alternative diagnoses (154,175). It is worth noting that a small subset of patients relapses once or twice after a 6-week course of antirheumatic therapy (176,177). The Jones criteria often fail to exclude other causes of febrile polyarthritis (48), and an alternative diagnosis may be made only as more chronic findings develop (i. Of particular importance is the fact that some patients thought to have poststreptococcal reactive arthritis have shown evidence of cardiac involvement (179,180,182,183). Conversely, a recent study showed no increased risk of valvular heart disease in a series of adults with poststreptococcal reactive arthritis (184). Given the uncertainty with respect to the risk of valvular heart disease for children with poststreptococcal reactive arthritis, some experts recommend that such patients undergo echocardiographic evaluation, receive secondary prophylaxis for up to a year after onset, and possibly undergo a follow-up echocardiogram after a year (185), but this is clearly an area of debate requiring further study. Chorea First described in the late 17th century, the association of chorea and rheumatism was not recognized until the 19th century. It is now known that the clinical manifestations of Sydenham chorea occur due to neuropathologic changes and inflammation in the basal ganglia, cerebral cortex, and the cerebellum (48,189). The gender distribution is equal in younger children, but after the age of 10 years, females are more often affected, and chorea is uncommon in postpubertal males (48). Involuntary, purposeless movements, muscular incoordination and/or weakness, and emotional lability characterize Sydenham chorea (48,49,190,191,192). Movements are abrupt and erratic, commonly affecting muscles of the face and extremities. Patients often come to attention based on deterioration in school performance, and neurobehavioral symptoms seen along with the chorea include irritability, poor attention span, lack of cooperation, and obsessive-compulsive symptoms are not uncommon. The neurologic manifestations are usually bilateral, but may be unilateral (hemichorea). The neurologic symptoms tend to decrease with rest and sedation and increase with effort or excitement. The median duration is about 15 weeks, and 75% show resolution of symptoms by 6 months (5,169,193). The latency period between the streptococcal pharyngitis and the onset of chorea is longer than for arthritis or carditis, ranging from 1 to 6 months (48,195). As previously stated, because of this longer latency period, arthritis and chorea rarely occur simultaneously. Also related to the longer latency period for patients presenting with chorea, acute phase reactants are often normal and antistreptococcal antibodies may not be elevated.

The standard deviation of time to minimal volume between 12 and 16 subvolumes is then used as a dyssynchrony index (Fig trusted 80 mg tadapox erectile dysfunction age 70. To account for different heart rates buy 80 mg tadapox otc erectile dysfunction statistics worldwide, the dyssynchrony index can be expressed as a percentage of the cardiac cycle length purchase discount tadapox on line erectile dysfunction medication online. Disadvantages of 3-D echo are the low frame rates and the indirect assessment of wall motion through assessment of volume change. Assessment of Mechanical Dyssynchrony in Children Dyssynchrony has been shown to be important in children and adolescents in a number of acquired and congenital conditions. Most studies have largely been restricted to investigating the prevalence of dyssynchrony in various conditions and investigating its impact on cardiac function, exercise capacity, and clinical outcomes. In children with dilated cardiomyopathy, and in normal controls, the degree of radial deformation (which is related to contractility) was found to be related to the time it took to develop peak deformation, thereby providing a direct link between timing of contraction and regional function (180). Diastolic dyssynchrony has also been found to be prevalent in this population and is possibly linked to increased risk for death or transplant (184). Dyssynchrony, demonstrated by echo, is also important in children with congenital heart disease. Likewise an increased interventricular delay has been linked with decreased exercise capacity and increased risk for ventricular arrhythmias during exercise (161). Whether this dyssynchrony constitutes a marker for later development of ventricular dysfunction in this population, is unknown. Indeed, increased mechanical dyssynchrony by tissue Doppler and strain imaging may be associated with decreased cardiac output after congenital heart disease surgery, and this may respond to biventricular pacing. The change in each subvolume over the cardiac cycle is represented in the curves at the bottom of the figure. Coronary Artery Physiology Coronary artery physiology and pathology play an important role in congenital conditions, and assessment of coronary artery physiology is gaining an increasingly important role for the pediatric and congenital echocardiographer. In children, coronary artery abnormalities are predominantly related to (a) an abnormal origin or course (e. The specific etiology in question will influence the type and extent of imaging performed. Two-dimensional and color flow echocardiography are useful for imaging coronary artery origins, course, aneurysms, and dilatation, but are less useful for detecting coronary artery stenosis, aside from perhaps coronary ostial stenosis. Coronary echocardiography or ultrasound can be divided into the following broad categories: 1. Assessment of regional myocardial function at rest and during stress that may indicate perfusion abnormalities in specific myocardial territories 3. Vascular imaging to detect early atherosclerosis In this section, we refer to general imaging of coronary artery physiology. Coronary physiology can be assessed by studying peripheral arterial structure and function or by direct interrogation of the coronary arteries themselves. The peripheral arteries serve as surrogate windows for the study of coronary artery physiology. Peripheral arterial endothelial function is assessed by brachial artery flow-mediated dilation. This technique involves inflating a sphygmomanometer cuff placed on the forearm or upper arm to a pressure of 100 to 150 mm Hg above the systolic pressure for 4 to 5 minutes. The brachial artery diameter immediately after cuff deflation is compared with the baseline diameter before inflation. The technique produces very subtle changes and must be performed in a highly controlled environment free of extraneous influences. Both carotid intima-medial thickness and brachial artery flow-mediated dilation have been used successfully to show impairment of vascular function, and therefore, presumably coronary arterial function in children with insulin-dependent diabetes mellitus (198,199). Vascular function can also be assessed by applanation tonometry, a nonultrasound technique that necessitates noninvasive capture of a large artery waveform using high-fidelity transducers and from which cardiovascular risk can be assessed (200). Direct assessment of the coronary arteries is still limited and a coronary abnormality should be considered when other signs of myocardial ischemia or infarction are present, such as global or regional ventricular dysfunction, ventricular and atrial enlargement, the presence of mitral regurgitation, echogenic papillary muscles or myocardium, and flow reversal in the left anterior descending artery by color flow Doppler in anomalous origin of the left coronary artery from the pulmonary artery. Direct functional assessment of the coronary arteries largely rests on Doppler assessment of coronary flow although it is not routinely performed in most pediatric clinical institutions. Nonetheless, Doppler flow velocities have been found to correlate well with invasive measurements by Doppler guide wire in adults and in pediatric studies, albeit in a small number of subjects (201,202,203). Normal values for Doppler flow velocities at rest in the left coronary artery have been published in a cohort of over 300 children (204), and have been studied in the branch coronary arteries (205). Velocities, which ranged up to 60 cm/s in young children, decreased with age and increased with heart rate. Coronary flow reserve reflects the increase in coronary flow in response to stimuli such as pharmacologic agents (e. It is calculated as the ratio of the peak (or mean) diastolic velocity after hyperemic stimulation to the baseline peak (or mean) diastolic velocity and reflects the resistance of the coronary bed, its ability to maintain constant flow when myocardial perfusion pressure changes (autoregulation), and the ability to augment blood flow in response to stress (206). Coronary flow reserve is affected not only by stenosis or compression of the proximal coronary arteries, such as in Kawasaki disease (203,207) or hypertrophic cardiomyopathy (208), but also by abnormalities in the distal coronary microvasculature such as in dilated cardiomyopathy, where decreased coronary flow reserve by Doppler echo has been linked to worse outcome (209,210). More reassuringly, normal coronary flow reserve has been found in a small study of children after arterial switch operation for transposition of the great arteries, although a number of children with left coronary anomalies demonstrated abnormal coronary flow reserve by cardiac positron emission tomographic imaging in response to adenosine (211). These normal findings in most children after the arterial switch operation mirror an invasive study using a Doppler guide wire and (212) may predict lower risk for atherosclerosis in the following decade (213). On the other hand, past publications have found that while coronary artery anatomy is not a determinant of outcome after the arterial switch operation, a portion of children may have silent ischemia without echocardiographic abnormalities at rest (214). Whether these children will demonstrate abnormal coronary flow reserve is unknown. Echo Doppler assessment of coronary flow reserve in the right coronary artery has also been shown to be feasible in an adult population, using a coronary Doppler flow wire as a reference (211). Given the important limitations of echocardiography in detecting coronary anomalies, especially those related to coronary stenosis and perfusion abnormalities, there should be a low threshold to proceed to other imaging modalities when there is a clinical suspicion of coronary stenosis or a perfusion abnormality. Coronary Perfusion One of the major uses of stress echocardiography is in the assessment of coronary perfusion (202). On the echocardiogram, ischemia is manifested by a new or worsening regional wall motion abnormality. In children, stress echocardiography for coronary assessment can be useful for a variety of indications including Kawasaki disease, detection of coronary artery vasculopathy in the transplanted heart (213,214), and after the arterial switch operation. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. Recommendations for quantification methods during the performance of a pediatric echocardiogram: a report from the Pediatric Measurements Writing Group of the American Society of Echocardiography Pediatric and Congenital Heart Disease Council. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Theoretical and empirical derivation of cardiovascular allometric relationships in children. Regression equations for calculation of z scores of cardiac structures in a large cohort of healthy infants, children, and adolescents: an echocardiographic study. Relationship of the dimension of cardiac structures to body size: an echocardiographic study in normal infants and children. Variability of M-mode versus two-dimensional echocardiography measurements in children with dilated cardiomyopathy. Comparison of two- and three-dimensional echocardiography with sequential magnetic resonance imaging for evaluating left ventricular volume and ejection fraction over time in patients with healed myocardial infarction.